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5. <br />6. <br />7. <br />8. <br />9. <br />Principal purpose of joint use dock is (check applicable items'): <br />provide boat mooring and lake access for residential property, <br />_____provide swimming access, beach, or offshore dock. <br />_____provide a club or association gathering place for activities. <br />Dock is locat’d on (check applicable item): <br />_____one member's private property. <br />easement or outlot owned in common. <br />___ property leased by the group/association. <br />___ property owned by the group/association. <br />List Dock location and ownership information: <br />Street address IvJ (jDV^ <br />Legal property description <br />PIP# <br />Listed property owner(s) ^ \I\fk. \I■ vjphiir PJiqnaJ <br />Names of abutting lakeshore property owners: <br />rNorth/W>er£t'> __________ <br />rMame(Name -h Address) <br />(South/Eastl <br />(Name + Address) <br />Names of other affected property owners: <br />^Oi/)ey _______________ <br />(Name + Address) (attach sheet if necessaiyO <br />Insurance Coverage - The jointly used dock is insured by one of the following.: <br />_____ property owner's homeowner's policy. <br />x/ separate group/association owned policy. <br />List the following information: <br />of insured (h ^MlAhciV^ ot TVlUO.lMl.Name <br />Name of insurance carrier Qpv\pi^fil CfimiJxA <br />Name of insurance agency _______________ <br />Policy Effective date of coverage Q^.Ol. <br />Amount of coverage: Public liability, per person, per occurre»ice $ 500, OOP _ <br />Public liability, per occurrence $ OD <br />Page 2 of 5